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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800577
Report Date: 07/14/2023
Date Signed: 07/14/2023 03:23:24 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/10/2023 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20230710114951
FACILITY NAME:VILLAGE AT SYDNEY CREEK, THEFACILITY NUMBER:
405800577
ADMINISTRATOR:KIRK P KLOTTHORFACILITY TYPE:
740
ADDRESS:1234 LAUREL LANETELEPHONE:
(805) 543-2350
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:84CENSUS: 66DATE:
07/14/2023
UNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Kirk Klotthor, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility exposes residents to hazardous facility grounds conditions
INVESTIGATION FINDINGS:
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On 7/14/23 at 10:43 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced 10-day complaint visit to the facility listed above. LPA met with Kirk Klotthor, Administrator, and explained the purpose of the visit.

On the allegation, “Facility exposes residents to hazardous facility grounds conditions,” the complainant was concerned that the areas along the sidewalks in the garden accessible to residents have holes with wires and water in them and has the potential for residents to stumble and get injured. To investigate, LPA toured the facility and interviewed the administrator.

Continued on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20230710114951
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE
FACILITY NUMBER: 405800577
VISIT DATE: 07/14/2023
NARRATIVE
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On 7/14/23 at 10: 50 am, LPA interviewed the administrator. The administrator states there was a plumbing leak in the garden and that a board was placed over a hole approximately 4 days ago. On 7/14/23, LPA toured the garden and observed a board in the flower bed covering the irrigation pipes. LPA walked on the board, sized approximately 2 feet x 2 feet, and walked on the soil to the right of it, approximately 4 feet long, and both were secure. There was no indication of the possibility of the board or surrounding area may collapse.

Based on the evidence obtained, the allegation, “Facility exposes residents to hazardous facility grounds conditions,” is deemed Unsubstantiated at this time.

Exit interview conducted, report given.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2